Clavicle fractures account for 44–66% of shoulder fractures. Evaluating degree of shortening is important when deciding between operative and non-operative treatment. The clavicle of a skeleton was marked at midpoint and junctions of the thirds along its superior surface. Antero-posterior (AP) and 30-degree upshot radiographs were taken. Images were analysed measuring distance between markers. In both AP and upshot images there were apparent discrepancies between lengths of each third and half. The main differences in apparent length appear in the measurement of the thirds of the clavicle. The AP made the medial third shorter compared to the middle and lateral third, whereas the upshot appeared to make the medial third shorter than the middle third with the lateral third shorter again. This study supports the theory that there is parallax error created by the shape of the clavicle. Middle third fractures account for 80% of fractures and both our AP and upshot images make the middle third appear longer in relation to lateral and medial thirds. This leads us to believe that shortening may be overestimated when measured using AP or upshot images. This leads us to advise caution when using WebPacs tools to measure shortening in clinical decision making.

The incidence of frozen shoulder (FS) as a complication of simple arthroscopic shoulder surgery has yet to be defined. A single-surgeon case series of patients undergoing arthroscopic subacromial decompression (ASD) or ASD with arthroscopic acromioclavicular joint (ACJ) excision was analysed to establish FS rate, this cohort was then compared to a matched group of primary FS patients.

Retrospective analysis of 200 consecutive cases was undertaken. All procedures listed, performed and reviewed by the senior author. 96 underwent ASD and 104 underwent ASD and ACJ excision. 6-months follow-up minimum.

Incidence of frozen shoulder was 5.21% (ASD) and 5.71% (ASD+ACJ excision). Mean age was 52.3 years (95% CI: 47.4 to 57.2) of the patients that developed FS, compared to 57.2 years (95% CI: 55.2 to 59.2) in the patients who did not and 52 years (95% CI: 50.7 to 53.3) in the primary FS cohort (n=136). 9.1% of post-operative FS were diabetic compared to 17.1% of primary FS. 63.6% were female in the post-operative FS group, 47.1% in the primary FS group.

Our results suggest that the risk of FS following simple arthroscopic procedures is 5%, with no increased risk if the ACJ is also excised.

This cohort has the same average age as a primary FS. There is a trend toward female sex and diabetes does not increase the risk.

We present (with intra-operative imaging) 4 patients who sustained Pectoralis major ruptures on the same piece of equipment of the “Tarzan” assault course at the Commando Training Centre, Royal Marines (CTCRM). Recruits jump at running pace, carrying 21 pounds of equipment and a weapon (8 pounds) across a 6ft gap onto a vertical cargo-net. The recruits punch horizontally through the net, before adducting their arm to catch themselves, and all weight, on their axilla.

All patients presented with immediate pain and reduced function. 2 had ruptures demonstrated on MRI, 1 on USS and one via clinical examination. All 4 patients were found, at operation, to have sustained type IIIE injuries.

All patients underwent Pectoralis major repair using a uni-cortical button fixation and had an uneventful immediate post operative course. Patient 1 left Royal Marines training after the injury (out of choice, not because of failure to rehabilitate). All other patients are under active rehabilitation hoping to return to training.

Review of 10 years of records at CTCRM reveal no documented Pectoralis major rupture prior to our first case in October 2013. There has been no change to the obstacle or technique used and all patients deny the use of steroids.

Quality Improvement (QI) is of increasing importance with its inclusion on training curricula and requirement for it in revalidation. Junior Doctors are a valuable, yet under utilised resource for NHS Trusts in patient safety/Quality Improvement activity.

A Trainee led QI Academy, supported and administered by Medical Education was launched in our Trust. It offered education on Leadership and Management and support for projects from the Trust Service and Development teams. The QI Academy launch evening attracted over 60 Trainees and 17 QI projects were adopted. Subsequently a further 9 projects have been started and a number published in peer reviewed journals and presented internationally.

The Academy was an attractive and supportive method of engaging new groups of doctors. QI is not as constrained as simple audit, and as such, engaging trainees has proven to be easier. Collaboration between a Core Faculty, Trainees and Trust Management ensured adequate and sustainable support for all projects, avoided duplication and fostered a closer relationship. We highly recommend Trust support of QI in junior doctors through Medical Education. Trusts benefit from improvements in patient care and quality whilst trainees learn valuable skills and benefit from presentations and publications.

Limited literature exists providing comprehensive assessment of complications following opening wedge high tibial osteotomy (OWHTO). We performed a retrospective study of local patients who underwent OWHTO for isolated medial compartment knee osteoarthritis from 1997–2013.

One hundred and fifteen patients met inclusion criteria. Mean follow-up = 8.4years. Mean age = 47 (range 32–62). Mean BMI = 29.1 (range 20.3–40.2). Implants used included Tomofix (72%), Puddu plate (21%) and Orthofix (7%) (no significant differences in age/ sex/ BMI). Wedge defects were filled with autologous graft (30%), Chronos (35%) or left empty (35%).

Five year survival rate (conversion to arthroplasty) = 80%. Overall complication rate = 31%. 25% of patients suffered 36 complications including minor wound infections (9.6%), major wound infections (3.5%), metalwork irritation necessitating plate removal (7%), non-union requiring revision (4.3%), vascular injury (1.7%), compartment syndrome (0.9%), and other minor complications (4%). No thromboembolic complications were observed.

A higher BMI (mean 34.2) was apparent in those patients suffering complications than those not (mean 26.9). No significant differences existed in complication rates relative to implant type, type of bone graft used or patient age at surgery.

Complications following OWHTO appear higher than previously reported in the literature; serious complications appear rare.

The correct prescription of antibiotics for in-patients is paramount to patient safety. Trust policy states that all in-patients on antibiotics must have a start date, duration, and indication for antibiotics documented on the drug-card. On a single day all drug-cards were reviewed assessing whether documentation was in line with policy. In the initial audit, 28 antibiotic courses were prescribed; of these courses only 15 (53.5%) had an indication documented and 15 (53.5%) had a review/stop date documented.

A monthly league table, coined ‘The Champions League’, was created. This named individuals who had correctly or incorrectly prescribed antibiotics, following identification in the monthly audit. It was published monthly and displayed in the doctors' office, on wards and circulated to all Consultants. After two published league tables, 19 antibiotic courses were prescribed. Indication was documented in 18 (94.7%) and 16 (84.2%) had the review date documented. This improvement has continued to the present day.

Prescribing standards appear to have improved with the use of this novel motivational tool. The competitive nature of surgical trainees has led to the Champions League becoming a talking point. Top placed doctors are rewarded with Premiership rugby tickets and those who consistently underperform are sensitively offered remedial instruction.

All licensed doctors are required to revalidate from June 2012. The GMC states that patient feedback should form part of doctors provided evidence. A standardised GMC PSS has been shown to offer a reliable basis for the assessment of professionalism among UK doctors and has been suggested as a tool for revalidation. We aim to show its use in the secondary care setting to be simple and effective, offering further evidence for doctors undergoing revalidation.

Having sought permission from the Trust the GMC PSS was used in the manner directed for 3 doctors in a Trauma and Orthopaedic fracture clinic. The data was analysed using an automated system and the results made available to individual clinicians in a simple to present format.

3 clinicians used the survey across 13 clinic sessions. The mean number of clinics it took to generate sufficient responses was 3.25 (range 2–5). We found the survey easy to use, HCAs handed forms to patients before consultation. Survey results were collected as patients left clinic and analysed by the Patient Services Department.

The GMC PSS, although designed principally for use in Primary care appears to be a useful tool in secondary care.

Femoral neck stress fractures (FNSF) are uncommon, representing 3.5% to 8% of all stress fractures in military recruits. The majority of displaced FNSF undergo operative fixation and are at risk of avascular necrosis (AVN) and non union with a 40–100% medical discharge rate. We aimed to review the incidence and outcome of displaced FNSF in Royal Marine Recruits.

Retrospective review identified 6 Royal Marine recruits, aged 17 to 25, who had suffered a displaced FNSF over a 6 and a half year period. Incidence was 0.93 per 1000 recruits.

Patients were treated urgently by operative fixation with a 2 hole dynamic hip screw device, in 3 cases supplemented with an anti-rotation screw. There were no cases of AVN, no surgical complications and no further procedures were required. All united with a mean time to union of 11 months. 50% had a union time greater than 1 year. 2 completed training, 2 are still in rehabilitation and 2 (33%) were discharged before completion of training.

These fractures are slow to unite compared to other fractures at this site or stress fractures elsewhere. With urgent surgical intervention and stable fixation all however went onto successful union with time and all returned to rehabilitation or training with minimal complications. Awareness of the length of time to union has been invaluable in guiding treatment and rehabilitation. It can help avoid the risks of unnecessary secondary interventions for delay to union.

Aim

The purpose of this study was to develop and test the utility of a hybrid barbed-suture in the core repair of digital flexor tendon injuries. Despite offering advantages over traditional suture methods, concerns over the cost, strength to failure and biocompatibility of barbed sutures have hindered their development. Moreover the recent designs have been very complex. We have attempted to develop and test a simple barbed suture, to assess it's viability in flexor tendon repair and in particular to establish a baseline for the efficacy and modes of failure barbed sutures, in order to help provide a basis for future research.

The Royal Marines regularly deploy to Norway to conduct Cold Weather, Arctic and Mountain Warfare training. A total of 1200 personnel deployed to Norway in 2010 over a 14-week period. Patients, whose injuries prevented them from continuing training, were returned to the UK via AEROMED. The aim of this investigation was to describe the epidemiology of musculoskeletal injuries during cold weather training.

All data on personnel returned to the UK was prospectively collected and basic epidemiology recorded.

53 patients (incidence 44/1,000 personnel) were returned to the UK via AEROMED. 20/53 (38%) of cases were musculoskeletal injuries (incidence 17/1000 personnel). 15/20 musculoskeletal injuries were sustained while conducting ski training (incidence 13/1,000): 4/20 were non-alcohol related injuries, 1/20 was related to alcohol consumption off duty. Injuries sustained whilst skiing: 5/15 sustained anterior shoulders dislocation, 5/15 Grade 1-3 MCL/LCL tears, 2/15 sustained ACJ injuries, 1/15 crush fracture T11/T12, 1/15 tibial plateau fracture and 1/15 significant ankle sprain. Non-Training injuries: 1 anterior shoulder dislocation, 1 distal radial fracture, 1 olecranon fracture, 1 Scaphoid Fracture and one 5th metatarsal fracture. 60% of injuries were upper limb injuries. The most common injury was anterior shoulder dislocation 6/20 (Incidence 5/1000)

Our results suggest that cold weather warfare training has a high injury rate requiring evacuation: 4% of all people deployed will require AEROMED evacuation, and 2% have musculoskeletal injuries. Ski training causes the majority of injuries, possibly due to the rapid transition from non-skier to skiing with a bergen and weapon. Military Orthopaedic and rehabilitation units supporting the Royal Marines, should expect sudden increases in referrals when large scale cold weather warfare training is being conducted. Further research is required to see if musculoskeletal injury rates can be decreased in cold weather warfare training.

High-energy pelvic ring fractures are associated with polytrauma where staged surgery is recommended. While temporary skeletal stabilisation is part of the acute management, definitive care is done in a later phase. The purpose of this study was to evaluate the safety and efficacy of acute pelvic ORIF by comparing its short term outcome with those who were stabilised late.

A 45-month retrospective review of the prospective pelvic fracture database of a level one trauma centre was performed. All high-energy trauma patients who were potential candidates for minimally invasive internal fixation of the pelvic ring were included. Patients were categorised as acute ORIF (<24 hrs) or late ORIF (>24 hrs). Demographics, ISS, pelvic AIS, 24 hour pack cell transfusions, physiological parameters, time to operating theatre, angiography requirement, LOS and mortality were recorded. Data was presented as mean+/−SD or percentages. Statistical significance was determined at ∗p<0.05 based on univariate analysis.

Forty-three patients met inclusion criteria, seventeen patients had acute definitive ORIF (5.5 hrs to OT) and twenty-six late definitive ORIF (5 days to OT). Acute and late ORIF patients had statistically not different demographics (age: 48+/−22 years vs 40+/− 14, gender: 82% vs 79% males), injury severity (ISS: 30+/−18 vs 24.5+/−13, pelvic AIS: 3.7+/− 1 vs 3.4+/− 1.1) and 24 hour transfusion (4.7+/−5 U vs 6.6+/−4 U). Initial shock parameters were significantly worse in the acute ORIF group (∗SBP 69.7+/−17 vs 108+/−21 mmHg, ∗BD -7.35+/−4 vs -4.9+/−1.5 mEq/L, ∗Lactate 6.67+/−7 vs 2.51+/−1.3 mmol/L). Angiography was used 18% (3/17) vs 21% (6/29) of the cases. All early ORIF patients survived and one (3%) of the late ORIF patients died. The trend in shorter hospital LOS was not significant in the early ORIF group (25+/− 24 vs 37+/− 32 days) while the ICU LOS was comparable (12/17 patients with 2.9+/−2.5 days vs 15/26 patients with 3.7+/−3.6 days).

Minimally invasive acute ORIF of unstable pelvic ring fractures could be performed even in severely shocked polytrauma patients. The procedure did not lead to increased rates of transfusion, mortality, ICU LOS or overall LOS. Furthermore, all these parameters showed a trend towards benefit compared to a staged approach.